Setting Three surgical units were involved in a prospective comparative study: the Pavillon Paul Gelle in Roubaix, France for vaginal hysterectomies; the Hotel Dieu Polyclinic in Clermont-Ferrand, France for total percoelioscopic hysterectomies; and the Saint-Luc Clinic in Brussels, Belgium for subtotal percoelioscopic hysterectomies.
Patients and Methods The inclusion criteria were age (38-55 years old), the patients were either not menopausal or else they had received alternative therapies for menopause, and had mild uterine pathology with or without castration signs, but without pelvic pain. The vaginal or coelioscopic approach had to be practicable. Those patients with psychiatric histories, or with prolapses or stress incontinence which demanded surgery were excluded. Contraindications to any of the approaches (uterine volume larger than umbilicus, major previous pelvic surgery, severe endometriosis and virginity) were also considered to be exclusion criteria. A total of 82 patients who had undergone 31 vaginal hysterectomies, 31 total coelioscopic hysterectomies and 20 subtotal coelioscopic hysterectomies were followed up 1 year after the operation.
Results The population characteristics in the three groups were similar. Operating times were 70.8 min for vaginal hysterectomies (VH), 67.6 min for total percoelioscopic hysterectomies (TPCH) and 111.5 min for subtotal percoelioscopic hysterectomies (SPCH). The mean hospital stay was comparable in the three groups. The mean uterine weight was 225 g for the VH group, 281 g for the TPCH and 206.5 g for the SPCH group (P was not significant). The pain evaluation scales used by the patients during their hospital stay did not show any significant difference between the three groups. The mean times before patients could walk, return to work or resume sexual intercourse showed no significant differences between the groups. Mild urinary signs were reported in the mid-term without any significant difference. Physical activity improved in 38.7% of the patients who had undergone VH, in 46.6% who had undergone TPCH and in 60% who had undergone SPCH (Pnot significant). Those patients who had undergone SPCH resumed satisfactory sexual intercourse significantly earlier (P = 0.0002). Intercourse was not significantly modified in the three groups. Quality of life was generally and significantly improved for 80.6%,96.5% and 70%, respectively, of the patients in the VH, TPCH and SPCH groups.
Conclusion Although some surgical teams are still reluctant to practise coelioscopic hysterectomies, all three hysterectomy types were finally demonstrated to be equivalent in this study. They were proved to be feasible even in patients with a large uterus. Operating times are no longer unfavourable factors when coelioscopies are performed by highly skilled surgeons.